Trauma Wastelands

Imagine finding yourself in a challenging situation while living in or exploring the diverse landscapes of the upper western states of the United States. Picture driving through Boise and encountering a massive 30-car collision amid thick fog, necessitating an airlift to the ICU. Envision a hiking mishap in Wyoming while in the renowned Yellowstone National Park, where a fall requires specialized medical attention. Now, place yourself in Pierre, North Dakota, a victim of a violent crime in dire need of immediate trauma care. In this expansive region encompassing Idaho, Montana, North Dakota, South Dakota, and Wyoming, a glaring absence of Level 1 trauma centers becomes apparent. Notably, none of these states currently possess a Level 1 trauma center, the highest tier known for delivering comprehensive services tailored to the most severe and complicated injuries.

Utilizing Geographic Information Systems (GIS), we can unravel crucial insights regarding population distribution, demographics, existing Level 1 trauma center locations, and the specific types of incidents or crimes that demand such advanced care. By leveraging GIS, we can also gauge the travel times, whether by road or air, required to access specialized medical facilities during critical situations. We won’t examine all of those insights in this story, but GIS can be used for future research in this area.

This analysis might reveal a bothersome reality: essential healthcare isn't always readily available or conveniently accessible in these expansive regions. This raises the important question: What strategic measures must be undertaken to enhance the availability of Level 1 trauma centers and ensure the provision of vital medical care when needed most?

As you scroll through the screen grabs below, notice the limited areas that even trauma flights can manage in this vast region.

Trauma centers can receive designation or verification, each level determined by available resources and annual patient admissions. National standards define these levels, differentiating between adult and pediatric care. Designation occurs at the state or local level, each establishing distinct criteria for classification. While criteria categories can vary by location, they are typically outlined by the local or state government. Verification, on the other hand, involves assessment by the American College of Surgeons. Their evaluation ensures appropriate trauma care provision and identifies areas for potential enhancement. This verification is voluntary and remains valid for three years.

In a previous study conducted in 2003, the count of trauma centers nearly tripled within a decade. Notably, there were 471 centers in 1991 and 1154 in 2003 (Mackenzie, et al., 2003). Presently, there are 2,229 total trauma centers, albeit not all attain Level 1 status.

The provided map shows the geographical positioning of Montana, Idaho, Wyoming, South Dakota, and North Dakota in relation to the region's verified Level 1 trauma centers. It's worth noting the presence of three such centers in Denver and two in Salt Lake City. A 2019 research initiative by Harvard scholars highlighted consistently inadequate Level 1 trauma availability in this region, relative to the discernible need. Although the study primarily concentrated on the requirements of geriatric patients, it remains imperative to acknowledge the prevalence of traumatic incidents necessitating escalated trauma care for all residents (Uribe-Leitz, et al., 2019).

A prior investigation conducted in 2010 revealed a correlation between undertriage, where critical patients were transported to non-trauma centers, and increased mortality rates (Haas, et al., 2010). Although this study primarily examines field triage, assessing the decision to transport patients directly to trauma centers, the core theme of this narrative revolves around the insufficient availability of Level 1 trauma centers to effectively accommodate these critical determinations.

Nonetheless, a challenge in addressing the undertriage issue is that effectively addressing all undertriaged patients would necessitate a nationwide capacity increase of 51.5% for Level I and II Trauma Centers (Xiang, et al., 2014). Is the medical community ready for this?

As previously indicated, the classification of trauma centers exhibits variability across different states. Presented below are prevalent criteria for Trauma Centers, endorsed by the American College of Surgeons (ACS), as well as designations established by states and local authorities. These facilities receive designations or verifications as Adult and/or Pediatric Trauma Centers. It is not unusual for a single facility to hold distinct designations for each group, resulting in scenarios such as a Trauma Center possessing a Level I Adult designation alongside a Level II Pediatric Facility classification.

A noteworthy observation pertains to the states of Montana, Wyoming, Idaho, North Dakota, and South Dakota, collectively encompassing approximately 13% of the total expanse of the United States, which amounts to 3.797 million square miles. This expansive square mileage contributes to positioning all five states within the top 20 in terms of size according to netstate data. Conversely, these states collectively account for less than 1% of the overall U.S. population, estimated at around 332 million (wisevoter). This stark contrast underscores the reality that over 123 million individuals lack convenient or immediate access to Level 1 trauma care. This number further fails to account for the substantial influx of millions of annual visitors to renowned destinations like Yellowstone National Park, Mount Rushmore, Hell’s Canyon, and Grand Teton National Park.

In this chart, I have juxtaposed the dimensions and populace of the states within the TC wasteland against those of the five most densely populated states. Although these latter states constitute around 15% of the entire expanse of the United States, their significant populations result in an extensive array of accessible Level 1 trauma centers, effectively catering to a substantial portion of their residents.

Billings, located in Yellowstone County, Montana, falls within the broader confines of Montana. The entire state's population stands at 1,104,274, while Yellowstone County itself accounts for 164,731 individuals. Yellowstone County constitutes approximately 15% of Montana's overall populace. Notably, the nearest Level 1 trauma center accessible to Billings, Montana is the University of Utah Hospital situated in Salt Lake City, Utah.

Upon conducting a distance analysis, the GIS program's limitations restricted my evaluation to a radius of 300 miles from the hospital. The results are depicted below:

The visualization underscores a concerning reality: individuals requiring traumatic care in Billings, Montana must undertake unsafe journeys to access effective medical assistance. This highlights the paramount significance of life flights in the present scenario and accentuates the pressing need for additional Level 1 trauma care facilities to safeguard the well-being of residents within this region of the nation. It's worth noting, however, that even air travel does not guarantee expeditious coverage over such extensive distances.

• Trauma Center Disparities: The upper western states of Montana, Wyoming, Idaho, North Dakota, and South Dakota collectively cover a substantial portion of the total U.S. land area, representing around 13% of the nation's expanse. However, these states are home to less than 1% of the overall U.S. population. Despite their vast size, the scarcity of Level 1 trauma centers in this region raises concerns about timely and accessible critical medical care.

• Undertriage Challenge: Addressing the issue of undertriage, which involves transporting patients to non-trauma centers, presents a substantial challenge. To accommodate all undertriaged patients, a considerable national capacity increase of 51.5% for Level I and II Trauma Centers would be required.

• Geographic Constraints: Geographic information system (GIS) analysis reveals that individuals in regions like Billings, Montana, face the challenge of limited access to Level 1 trauma centers. The analysis illustrates that individuals must travel unsafe distances to access adequate care, emphasizing the importance of life flights and the urgent need for additional Level 1 trauma centers in remote areas.

• Tourism Impact: The inadequacy of trauma centers not only affects local residents but also poses challenges for the millions of tourists who visit iconic destinations within these regions each year, such as national parks.

In summary, the findings underscore the disparity in trauma center availability across different regions of the United States, with a particular focus on the upper western states. This discrepancy has significant implications for timely and effective medical care, highlighting the need for increased trauma center capacity, improved access to critical care facilities, and consideration of the unique challenges posed by geographical factors.

Something of note, the Billings Clinic in Billings, Montana, is in the process of obtaining Level 1 trauma certification. While adding this location will help, it still leaves a large portion of the region without adequate coverage.

Although this project was centered on specific states, an interesting incident came to my attention via a short video shared on Facebook last Sunday. The video featured a nurse who routinely took time off during a particular week every July. The reason behind this unique schedule was an event called RAGBRAI, held in the state of Iowa. During RAGBRAI, a spirited group of Iowans indulge in ample libations and embark on a daring quest to cycle across the entire state. The video humorously highlighted the surge of patients flooding into the lone Level 1 trauma center in Iowa due to this event. This anecdote underscores that the issue of inadequate trauma center availability isn't confined solely to the upper western states; it appears to be a challenge experienced in other regions as well.

NSTATE, L. (n.d.). 50 state rankings for size. 50 States in Square Miles from NETSTATE.COM. https://www.netstate.com/states/tables/st_size.htm 

States by population 2023. Wisevoter. (2023, May 30). https://wisevoter.com/state-rankings/states-by-population/ 

American Trauma Society. (n.d.). Find Your Local Trauma Center. https://www.amtrauma.org/page/FindTraumaCenter 

Q2 News (KTVQ). (2022, March 24). Billings Clinic moves to become Montana’s first Level 1 Trauma Center. Q2 News (KTVQ). https://www.ktvq.com/news/local-news/billings-clinics-moves-to-become-montanas-first-level-1-trauma-center 

Uribe-Leitz, T., Jarman, M. P., Sturgeon, D. J., Harlow, A. F., Lipsitz, S. R., Cooper, Z., Salim, A., Newgard, C. D., & Haider, A. H. (2020). National Study of Triage and Access to Trauma Centers for Older Adults. Annals of emergency medicine, 75(2), 125–135.  https://doi.org/10.1016/j.annemergmed.2019.06.018 

Haas, B., Gomez, D., Zagorski, B., Stukel, T. A., Rubenfeld, G. D., & Nathens, A. B. (2010). Survival of the fittest: the hidden cost of undertriage of major trauma. Journal of the American College of Surgeons, 211(6), 804–811.  https://doi.org/10.1016/j.jamcollsurg.2010.08.014 

Xiang, H., Wheeler, K. K., Groner, J. I., Shi, J., & Haley, K. J. (2014). Undertriage of major trauma patients in the US emergency departments. The American journal of emergency medicine, 32(9), 997–1004.  https://doi.org/10.1016/j.ajem.2014.05.038 

MacKenzie, E. J., Hoyt, D. B., Sacra, J. C., Jurkovich, G. J., Carlini, A. R., Teitelbaum, S. D., & Teter, H., Jr (2003). National inventory of hospital trauma centers. JAMA, 289(12), 1515–1522.  https://doi.org/10.1001/jama.289.12.1515